Deprescribing: A Graduation in Medicine

https://doi.org/10.7812/TPP/18-071-21

From Northern California

Background: By 2050, the US Census Bureau projects that the US population of adults older than age 65 years will nearly double. Human aging results in physiologic changes, frailty, and added comorbidities that require multiple medications to treat age-related medical conditions. Accordingly, the issue of polypharmacy is increasingly reported in the literature. With more medications, elderly patients tend to have complex medication regimens, often leading to nonadherence, adverse drug events, and a reduced quality of life.Methods: In partnership with Kaiser Permanente (KP) Northern California Clinical Pharmacy, The Permanente Medical Group Quality, Primary Care, subject matter experts, the Institute for Healthcare Improvement, and the Commonwealth Fund, we designed a pharmacist-led deprescribing program to reduce potentially unnecessary/unsafe medication use in the elderly. Targeted initiatives: Well-controlled diabetes and blood pressure, chronic nonsteroidal anti-inflammatory drugs, controlled triglycerides on fibrates, and glucose test strips. Additionally, internal and external partnerships were established to ensure effective dissemination of resources for the deprescribing movement. Although deprescribing exists in KP in siloed forms, we aim to address the big picture by establishing central deprescribing resources, sharing broadly, and supporting deprescribing conversations in all settings.Results: The project went from idea to regionwide operation in 4 months. During the 15 months of operations since, the pharmacist-led deprescribing program has touched more than 5000 patient lives and decreased medication/self-testing burden for nearly 3000. Clinical and financial outcomes research is underway. An interim analysis showed 95% of patients with diabetes maintained goals of hemoglobin A1c < 7.5% (n ~ 500) and 97% of blood pressure patients maintained goals of systolic blood pressure < 140 (n ~ 40) at 90 days postdeprescribing. The Permanente Medical Group and KP Northern California Clinical Pharmacy worked together to establish partnerships on this topic of deprescribing and polypharmacy. The team also received a grant from the Institute for Healthcare Improvement and Commonwealth Fund to apply performance improvement principles to the pharmacist-led deprescribing programs.Discussion: A broad range of partnerships is crucial to creating a movement in health care: Nimble use of technology is vital. The core team created a central OneNote. Structured query language algorithms were quickly created and adjusted to identify potential patients to include in the program. Custom KP HealthConnect data elements were built. Tableau was used for automated dashboards. Performance improvement ensures monitoring toward goals. The team applied driver diagrams, process charts, Plan-Do-Study-Act cycles, run charts, Model for Understanding Success in Quality assessments, strengths, weaknesses, opportunities, and threats analysis, aim statements, and more. Research: The project is building the foundations of research for patients who have participated in the deprescribing program. Next steps are to spread the message of deprescribing systematically.